Urogenital Tuberculosis: Classification, Diagnosis, and Treatment

An Unusual Case Report of Male Genital Tuberculosis

The burden of extrapulmonary tuberculosis (EPTB) is significant, constituting up to 20% of all TB cases in HIV-negative patients and 50% of new cases in HIV-positive individuals. However, diagnosing EPTB remains challenging due to its pauci-bacillary nature and the necessity for invasive sampling methods in many forms of the disease. Urogenital tuberculosis represents approximately 4% of the annual cases of extra-pulmonary tuberculosis in India, with isolated testicular tuberculosis being a particularly rare manifestation. In this report, we present three cases of testicular tuberculosis, diagnosed through tissue biopsy and Acid Fast Bacilli (AFB) smears.

The challenges in diagnosing isolated epididymal tuberculosis (TB) in an adolescent male: a case report

BACKGROUND

Genitourinary tuberculosis (GUTB) is a common form of extrapulmonary TB (EPTB) in children. An example of GUTB is epididymal TB, which usually presents unspecific chronic clinical manifestations. Definitive diagnosis can be conducted based on bacteriologic confirmation and histopathologic results, but this is challenging due to the paucibacillary nature of EPTB. Therefore, we reported the challenges in diagnosing isolated epididymal TB in an adolescent male.

CASE PRESENTATION

A 16-year-old male presented to respirology clinic with painful swelling of the left scrotum for 3 months before visiting to the hospital. The symptoms were associated with persistent coughing for 2 months, and physical examination of the left scrotum showed swelling accompanied by cardinal signs. A palpable hard mass was found on the left scrotum, with firm borders, measuring 7 × 4 cm. Laboratory examination and tumor markers were within normal limits, although leukocyturia was found, and the urine culture was negative. Genital ultrasound (US) showed epididymitis sinistra with septal hydrocele, while magnetic resonance imaging (MRI) indicated inhomogeneous left epididymitis with bilateral inguinal lymph node enlargement. Although TB evaluation presented a negative purified protein derivative (PPD) test and bacteriologic examination, chest X-ray (CXR) showed perihilar lymphadenopathy. Based on the clinical and radiologic results suggesting TB, the patient was diagnosed with isolated epididymal TB and received quadruple antituberculosis therapy (ATT) for 6 months. After treatment, the left testicle size started to shrink and was equal to the right testicle, also, there were no signs of inflammation, the body weight increased by 5 kg, and cough disappeared. Sperm analysis at the end of treatment indicated teratozoospermia, which was subsequently treated by the urologic surgery department.

CONCLUSIONS

Biopsy and bacteriologic confirmation for TB epididymitis were challenging to perform in the clinical setting. Epididymal TB should be considered in adolescent males with complaints of chronic scrotal swelling and pain. Clinical judgment based on history taking, physical examination, and radiologic features supporting TB features could be helpful in accurate and fast diagnosis for favorable outcome.

Imaging of infra-thoracic tuberculosis

Tuberculosis (TB) is a potentially curable disease that is a leading cause of death globally. While it typically affects the lungs, this disease may involve many extra-pulmonary sites, particularly in patients with risk factors. Extra-pulmonary TB often mimics a variety of different diseases, posing a diagnostic dilemma. Imaging aids in early diagnosis of TB, especially in patients with non-specific or atypical symptoms found at extra-pulmonary infra-thoracic locations. Imaging also helps guide appropriate laboratory investigation, monitor disease progress, and response to treatment. This review aims to highlight the imaging spectrum of TB affecting the infra-thoracic region, that is, gastrointestinal tract, abdominal lymph nodes, peritoneal cavity, intra-abdominal solid organs, and urogenital system.

A rare case of disseminated genitourinary tract tuberculosis complicated by emphysematous prostatitis and seminal vesicle abscess

Urogenital tuberculosis (UGTB) can affect the entire urinary tract including the kidneys, ureters (strictures), urinary bladder, prostate in addition to involving reproductive tracts. In modern day practice, both ultrasound and cross-sectional imaging play an important role in the radiological diagnosis of UGTB. The sequalae of untreated UGTB is morbid and can lead to end-stage renal failure, infertility, and life-threatening systemic infection. UGTB is less commonly observed in developed countries and may mimic other pathologies including malignancy. Thus, it is important that radiologists consider the differential diagnosis early, particularly individuals with risk factors such as travel to endemic regions, to allow optimal treatment and ensure best prognostic outcomes. UGTB can typically be managed by Infectious Disease clinicians with multidrug chemotherapy. We have presented a case of microbiologically proven extrapulmonary tuberculosis (TB) predominantly involving the genitourinary tract. The response to TB agents and lack of evidence of co-infection with another organism, might suggest this as the first published case of emphysematous tuberculous prostatitis. Emphysematous prostatitis is indicative of a gas-forming infection of the prostate, and is associated with abscess formation in the vast majority of case and is an easily identified radiological feature on CT. It is not a well-recognised feature of Mycobacterium tuberculosis infection and thus microbiological diagnosis should be sought to confirm the diagnosis.

Immune disturbances in female genital tuberculosis and latent genital tuberculosis

BACKGROUND

Female genital tuberculosis (FGTB), an important clinical sub-type of extra-pulmonary tuberculosis (EPTB) is responsible for about 10% cases of infertility in India. Both FGTB and latent genital tuberculosis (LGTB) can cause infertility through blockage of fallopian tubes and through altered uterine endometrial receptivity.

AIMS

This review tries to elucidates the role of various immune factors in FGTB and LGTB.

CONTENT

Various immune disturbances are observed in FGTB and LGTB like growth factors and cytokines which inhibit implantation and several inflammatory signaling pathways like mitogen activated protein kinase (MAPK), natural killer (NK) cells, nuclear factor kappa-B (NF-KB), tumor necrosis factor (TNF), and toll like receptors (TLR) signaling are dysregulated. These altered immune factors and pathways may be detected in the endometrial biopsies at the early stages of disease before permanent damage. Prompt and adequate treatment with the four anti-tubercular drugs (rifampicin [R], isoniazid [H], pyrazinamide [Z], and ethambutol [E]) can increase pregnancy rates in some of these women. Assisted reproduction especially in-vitro fertilization and embryo transfer may be required for some women.

IMPLICATIONS

Inflammatory pathways identified from the gene profiling have enabled development of potential biomarkers for early diagnosis of FGTB. Immunomodulation and novel biotechniques like stem cell transplantation, nanoparticles and host directed therapies are being tried in selected patients of FGTB and LGTB with promising results.

Dynamics of the structure of renal tuberculosis over 20 years

Background. Tuberculosis is a serious medical and social problem that does not lose its importance, despite all the advances in pharmacology and surgery. Diagnosis of urogenital tuberculosis (UGTB), as a rule, is delayed due to low index of suspicion to tuberculosis and the absence of pathognomonic symptoms. Aim. Determining the change in the ratio of clinical forms of renal tuberculosis from 1999 to 2020. Materials and methods. A retrospective cohort comparative non-interventional study on the spectrum of the incidence of extrapulmonary tuberculosis (EPTB) was carried out. Among all 13852 extrapulmonary tuberculosis patients which were diagnosed from 1999 to 2020, patients with renal tuberculosis were selected, and the spectrum of their clinical forms in three periods was analyzed: 1st period 19992004 (1155 patients), second period 20052014 (2657 patients), and the third period 20152020 (671 patients). The clinical features of nephrotuberculosis in 88 patients was also estimated. Results. Over the 20 years of the analyzed period, the number of patients with UGTB decreased by 80.6%; for the year of the COVID-19 pandemic, this figure fell by another third. In the first period, destructive complicated forms of nephrotuberculosis prevailed (922 patients 79.8%), while the so-called "minor forms" were diagnosed in 233 patients (20.2%). In the second period, the situation was statistically significantly more favorable: the proportion of destructive and complicated forms of renal tuberculosis decreased to 43.8% (1124 patients), "small forms" were diagnosed in 1443 patients (56.2%). In the third period, destructive and complicated forms of nephrotuberculosis were diagnosed in 531 patients (77.6%), and the proportion of "small forms" in comparison with the previous period decreased by half, to 22.4%. Analysis of the clinical features of renal tuberculosis, depending on the prevalence of the destruction, showed that an asymptomatic course is possible, and pain, dysuria, intoxication and renal colic are present with different frequencies, and the clinical picture of tuberculosis of the renal parenchyma differs significantly from the clinical picture of tuberculous papillitis, cavernous nephrotuberculosis and symptoms of renal tuberculosis as whole. Conclusion. Currently, there is no screening on urogenital tuberculosis at all. Patients are diagnosed by referral, with a long history, after receiving multiple courses of antibacterial treatment; mainly through the pathomorphological examination of the operating material. Thus, a sharp decrease in the proportion of UGTB patients does not mean the disappearance of tuberculosis of this localization, but only states the tragic defects in timely diagnosis and low index of suspicion of medical doctors in relation to UGTB.

Tongue cancer in a patient with pulmonary tuberculosis. Case report

Tuberculosis and malignant neoplasms are a global threat, these diseases claim millions of lives and cause tremendous suffering to people worldwide. Tuberculosis can mask cancer and create preconditions for carcinogenesis. The article presents a clinical case of tongue cancer in a patient with pulmonary tuberculosis. Patient B.N., 45 years old, was admitted to the FSBI Novosibirsk Tuberculosis Research Institute with complaints of a "sore place" on the tongue, pain in the right half of the tongue, enlargement of the submandibular lymph nodes on the right The tongue hurts for about 1,5 years, but over the last 2 months, condition has worsened. The patient noticed an increase in the size of lesion on the tongue and increased pain, especially during meals (he can eat only after pain relief, for which he takes Nimesulide 4 pills a day). In recent days, he felt also epigastric pain for which he didnt visit a doctor. Tongue biopsy was performed, and histological analysis revealed cancer. The patient was diagnosed with fibrous-cavernous tuberculosis of the upper lobe of the right lung, infiltration and seeding phase; mycobacterium tuberculosis (+); broad drug resistance (HRSECmKmPasCsOfl); gastric ulcer (0,5 cm), exacerbation stage; chronic erosive gastritis, exacerbation stage; malignant neoplasm of the floor of the mouth on the right T3(4)N1M1. With this diagnosis, the patient was discharged for further treatment by oncologists. Physicians need to have a high alertness for cancer in patients with tuberculosis, especially those in the high-risk group. A minimum of standard diagnostic procedures will allow you to verify the diagnosis timely.

Surgical management of tuberculous epididymo-orchitis: a retrospective study of 81 cases with long-term follow-up

BACKGROUND

Nowadays, most studies of tuberculous epididymo-orchitis (TBEO) are case reports or small sample cohort series. Our study is aimed to present the largest series of TBEO with our management experiences and long-term follow-up outcomes.

METHODS

Patients diagnosed with TBEO after surgical procedures at Department of Urology, West China Hospital from 2008 to 2019 were included. All clinical features, auxiliary examination results, treatment and histopathological findings were extracted if available.

RESULTS

Eighty-one patients (mean age 50.77 ± 16.1 years) were included. Scrotal swelling (N = 47, 58.0%) and pain (N = 29, 35.8%) were the most common presenting complaint. Pyuria and microscopic hematuria were observed in twenty-two (27.2%) and eight patients (9.9%), respectively. Urine acid fast bacilli cultures were available in 16 patients and all were negative. The mean duration between the onset of symptoms and the definite diagnosis was 6.42 ± 7.0 months. TBEO was considered in 30 (37.0%), tumors in 28 (34.6%) and nonspecific bacterial epididymo-orchitis in 23 (28.4%) patients. All patients received triple therapy of chemotherapy-surgery-pharmacotherapy and definite diagnosis was confirmed through histopathology of surgical specimens. Fifty-five patients were followed up regularly (mean follow-up 82.35 ± 36.6 months). One patient (1.2%) died from liver cirrhosis and no recurrence was observed. Postoperative complications included erectile dysfunction in 4 patients (4.9%), premature ejaculation in 5 patients (6.2%) and sterility in 7 patients (8.6%).

CONCLUSIONS

We recommend patients with advanced TBEO to receive triple therapy of chemotherapy-surgery-pharmacotherapy. Physicians should pay more attention to patients' sexual function and fertility during follow up after treatment completed.

Renal abscesses refractory to treatment: Have you thought of tuberculosis?

Urogenital tuberculosis is the commonest extrapulmonary tuberculosis after lymphadenitis, with the kidneys being the most frequently affected organ. The clinical manifestation of renal tuberculosis is frequently nonspecific, leading to many overlooked cases especially in a developed country. Herein, we report a case of renal tuberculosis in a 79-year-old Caucasian lady who presented with recurrent renal abscess refractory to antibiotics.

Level of evidence: Level 5

Urogenital tuberculosis - epidemiology, pathogenesis and clinical features

Tuberculosis (TB) is the most common cause of death from infectious disease worldwide. A substantial proportion of patients presenting with extrapulmonary TB have urogenital TB (UG-TB), which can easily be overlooked owing to non-specific symptoms, chronic and cryptic protean clinical manifestations, and lack of clinician awareness of the possibility of TB. Delay in diagnosis results in disease progression, irreversible tissue and organ damage and chronic renal failure. UG-TB can manifest with acute or chronic inflammation of the urinary or genital tract, abdominal pain, abdominal mass, obstructive uropathy, infertility, menstrual irregularities and abnormal renal function tests. Advanced UG-TB can cause renal scarring, distortion of renal calyces and pelvic, ureteric strictures, stenosis, urinary outflow tract obstruction, hydroureter, hydronephrosis, renal failure and reduced bladder capacity. The specific diagnosis of UG-TB is achieved by culturing Mycobacterium tuberculosis from an appropriate clinical sample or by DNA identification. Imaging can aid in localizing site, extent and effect of the disease, obtaining tissue samples for diagnosis, planning medical or surgical management, and monitoring response to treatment. Drug-sensitive TB requires 6-9 months of WHO-recommended standard treatment regimens. Drug-resistant TB requires 12-24 months of therapy with toxic drugs with close monitoring. Surgical intervention as an adjunct to medical drug treatment is required in certain circumstances. Current challenges in UG-TB management include making an early diagnosis, raising clinical awareness, developing rapid and sensitive TB diagnostics tests, and improving treatment outcomes.